Canada faces an unprecedented oversupply of orthopaedic surgery graduates, many of whom can only find precarious work as locum tenens or are forced to look for work offshore. Many factors contribute to the situation. Chief among them, though, are austerity measures initiated by provincial health ministries that have effectively cancelled a projected expansion of human health resources in general and orthopaedic resources in particular.

It’s not as though Canada does not need these new surgeons. Demand for orthopaedic services is greater than ever. Indeed, early in the last decade, governments and universities went to a great deal of trouble and expense to increase orthopaedic residency positions by about 90 percent.

The talented young men and women who were recruited to fill those spaces are now for the most part facing very real struggles, often working as itinerant contract trauma surgeons covering call for established surgeons or doing serial fellowships until conditions change. Eventually, a number of these young surgeons will find their niche, often by chance, because generational turnover will open up existing positions at just the right moment.

Such underemployment, however, is a systemic problem that will take years to resolve and many rounds of delicate negotiations to reduce the number of residencies to sustainable levels. It’s a painful predicament.

What can be done?
These long-term market forces may be mostly beyond the control of the Canadian Orthopaedic Association, but how our profession responds in the meantime to this difficult situation is not. I propose a return to an old-fashioned virtue: teamwork. By this, I don’t mean a group of individual surgeons who like to work together because their personalities are compatible and their skills are complementary—although that seems a minimum for team-building.

I believe something more formal is needed, where the team practice is delineated in detail so that roles and responsibilities are clear and transparent, where there is a forward-looking strategic plan to nurture the practice and the profession, and where patient-centered care trumps all other considerations.

The locum tenens dilemma
In Canada, the locum tenens role has become a type of “gray market” for unemployed orthopaedic surgeons, enabling some established surgeons to divest themselves of their emergency call obligations. One can argue that trauma call is the only regular work available and graduates should count their blessings, but there are some serious flaws in this line of thinking.

First is the loss of other specialty skills. In addition, the potential for abuse is obvious, because contract workers have no say in how the work is meted out. Also, their careers can be at risk if something should go wrong and patient hand-over protocols are not as rigorous as they should be.

Even more concerning is the question of whether “remote management” of an emergency trauma patient by an established surgeon through a contract worker compromises optimal outcomes. It’s hard to imagine how these types of locum positions are an example of best practices.

I believe we need to return to the traditional locum tenens, where the “placeholder” surgeon substitutes for a brief amount of time, covering both elective and call work. If a practice has real concerns about the amount of trauma call obligations they need to fulfill, then the team should consider hiring an orthopaedic surgeon with an interest in trauma. Let’s give some real work to these young surgeons who have had a steady diet of trauma, and while we are at it, let’s argue for resources to look after injured patients during daytime hours, which will have a positive impact on the surgeons delivering trauma care and will improve outcomes for patients.

At the heart of the underemployment/unemployment crisis lies an existential question: Are today’s orthopaedic surgeons willing to share some of their closely guarded resources with a new generation of surgeons who have no access to new resources? Can we change the models for our practices to allow intergenerational practice integration in a manner different from what has been done for decades?

Canada is very close to the United States—your “neighbor to the north.” Knowing that orthopaedic surgeons are in short supply in the United States, can we find opportunities for some Canadian orthopaedic graduates to assist in filling some vacancies in the United States? Canadian and American orthopaedic professional organizations have had a strong association for decades, and mutual cooperation will continue to benefit patients in our respective countries.

I personally see these challenges as an opportunity for a positive change and ultimately for the continued growth and success of the profession.

Bas Masri, MD, FRCSC, is the current president of the Canadian Orthopaedic Association and a professor, head of the department of orthopaedics, and medical director for the Centre for Surgical Innovation at the University of British Columbia.

Editor’s Note: This is another in a series of articles by the presidents of orthopaedic associations from around the world. Each article will cover an issue relevant to that country or organization that is also of interest to U.S. orthopaedic surgeons. The previous article Orthopaedic Training in South Africa.